Writing Effective Treatment Plans

The treatment plan is the foundation of ongoing excellent documentation.

Unfortunately, the information that should go into a treatment plan and its relationship to the other components of the patient’s chart is often misunderstood. When treatment plans are incomplete, incoherent, or missing altogether, good case management can be difficult to achieve. This can leave staff with scheduling difficulties, patients with unclear expectations about their treatment, and insurance companies denying claims because the medical necessity of care has not been proven.

Treatment plans are created after the patient’s initial history, examination, and assessment have been completed. Developing an effective treatment plan should result from the medical decision-making process of the Evaluation and Management (E/M) service. Information gleaned from the initial visit intake forms, doctor consultation, examination, outcome assessment tools, etc. helps to determine the patient’s treatment protocols. The treatment plan should be customized for every patient and may change throughout the patient’s course of treatment based on patient progress.

Important information that must be included is as follows:

• Treatment Protocols: This is the who, what, where, when, and why of the treatment plan. Outline the expected time frame of the episode. Note what spinal and/or extra spinal regions have primary or compensatory subluxations and the adjusting techniques that will be used to correct them. The protocols also include information about therapy and modalities that are recommended by the doctor, along with rationale for each service. Indicate the frequency and duration of these treatments. Make note of any orthotics, supplements, or other over-the-counter supplies that are recommended for the patient.
• Functional Treatment Goals: Goals should be functional, specific, measurable, and attainable. The best treatment goals can be created using information from the patient’s reported functional deficit and the Outcomes Assessment Tools (OATs) since they assess various aspects of a patient’s Activities of Daily Living (ADLs). Statements such as “reduce pain” or “increase range of motion” are too vague to be used in a treatment plan. A better goal would be “to reduce pain from a 6 to a 3 within one month” or “increase the patient’s ability to stand without pain from his current state of 15 minutes to one hour within one month.”
• Treatment Effectiveness: It’s expected that providers explain how they will know if the treatment is working. Is that simply “pain reduced”? I hope not. Use the OATs scores to define an additional parameter for measuring the progress of your plan. Note the initial scores and the goal scores in the treatment plan. These scores should be updated about every 30 days during the re-evaluation visits with a notation of how the results reflect the patient’s progress.
• Date of Expected Re-evaluation or Discharge: No one expects the doctor to be a mind reader and to know the exact date the patient will reach maximum therapeutic benefit from treatment. Re-evaluations should take place about every 30 days to check in on the patient’s progress and create an updated treatment plan. The doctor may decide to try a therapeutic withdrawal before discharging the patient and this should be documented. Treatment plans can also be written for maintenance patients after they have been discharged from active care.
• Home Care Instructions: Patients may be given home exercises to complete or asked to make dietary or lifestyle changes as part of their treatment. Any modifications or restrictions to their workplace or schedule must be documented. Suggest suitable alternatives if possible, and the time frame for the restrictions.

Although a treatment plan is a separate component of your documentation, it can also be changed or updated within your daily notes outside a formal E/M service if appropriate. For example, due to quicker than expected progress, therapeutic exercises may be started sooner than expected.

Treatment plans need to be in writing; they must be complete, and they must be compliant. Their purpose is to show the steps the doctor plans to take to help patients return to their previous state of health or as close to it as possible. Be sure to document plans for each phase of care and watch as your patients achieve their chiropractic goals.

Dr. Colleen Auchenbach graduated with a Doctor of Chiropractic from Cleveland University Kansas City in December of 1998 and enjoyed practicing for over 20 years. Her interest in Medical Compliance began when she earned the 100-hour Insurance Consultant/Peer Review certification from Logan University in 2015. She has been a certified Medical Compliance Specialist-Physician since 2016 and a Certified Professional Medical Auditor since 2022. Dr. Auchenbach joined the excellent team at KMC University as a Specialist in 2020, and as a part of this dedicated team is determined to bring you accurate, current, and reliable information. You may reach her by email at info@kmcuniversity.com or by calling (855) 832-6562.